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! COUNTY NAME <br /> SITE NAME: INSPECTION DATE: <br /> SITE ADDRESS: 6;ZZ 1 U hl E CITY/STATE/ZIP <br /> CHANGES SITE/OWNER/PERMIT? YES NO TANK ixo GA TANK wcn vl - TANK lfmn ens TANK Bacc <br /> MFR/PERMIT SUBMITTED o. I ID• Z o 03 0 <br /> TYPE OF INSPECTION�.�iL- SITE COMPUTER• PER• PER• PER• PER• <br /> ,Ia.-)v �&MbOR DATE EXP.DATE EXP.DATE EXP.DATE <br /> OPERATIONAL TANK MAJ MIN <br /> PERMIT TO OPERATE 1121 1 <br /> CHANGE IN CONDITIONS TO OPERATE 31 J41 1 <br /> APP 40VED CONSTRUCTION 6 1 8 <br /> VVRITTEN MONITORING PROCEDURES 7 181 <br /> -APPROVED MONITORING SYSTEM 9 10 <br /> MONITORING SYSTEM 11 12 <br /> APPROVED MONITOR FREQUENCY Q 14 <br /> MONITORING RECORDS MAINTAINED 15 16 <br /> ACCESS CASINO SECURED 17 10 <br /> PIPING 19 20 <br /> INVENTORY RECONCILIATION 21' 22 <br /> TANK GAUGING 231 1241 <br /> APPROVED RESPONSE PLAN 251 261 , - <br /> UNAUTHORIZED RELEASE OCCURRENCE 271 26 <br /> SAMPLING 29' 30 <br /> APPROVED TANK REPAIRS 31 32 <br /> UNAUTHORIZED RELEASES REPORTED 33 34 <br /> SAFETY HAZARD 35, 36 <br /> CONDITIONS ABATED 37 <br /> TEMPORARY TANK CLOSURE <br /> REMOVAL OF RESIDUAL 3B, 39 <br /> FLAMMABLE VAPORS REMOVED <br /> ACCESS LOCATIONS SEALED 1 42' <br /> POWER DISCONNECTED 43 <br /> OWNER/OPERATOR MONITORING <br /> PERMANENT TANK CLOSURE <br /> REMOVAL OF RESIDUAL MATERIALS 461 47 <br /> PIPING 46 49 <br /> FLAMMABLE VAPORS REMOVED 50 <br /> UNAUTHORIZED RELEASE 111 52 <br /> SAMPLING 531 54 <br /> IMPROPER ABANDONMENT 551 56 <br /> THE MARKED ITEMS REPRESENT VIOLATIONS AND MUST BE CORRECTED AS <br /> SYSTEM STATUS(MUST MINK ONEI FOL 4 <br /> LWOR C <br /> 57 58 <br /> ,$� r <br /> OR <br /> VIOL ❑ OL ❑ VVIiOL. - <br /> S Rh6KUN LOCAL HEALTH DISTRI NSP r, rcc (, RECEIVEDBY: <br /> POST OFFICC E30X 2009 <br /> STOCKTON. CALIF. 85201 <br /> N: ENVIRON. HEALTH T�ES;i ,fa�:,a „ I'�G` <br />